Private Medical Insurance (PMI) is designed to cover the cost of private medical treatment for ‘acute conditions’ which start after your policy begins.

Acute Conditions.

Acute pain is defined as pain of short duration; it has an identifiable cause and a predictable prognosis. It is usually of rapid or recent onset and is often severe.  An acute condition is a disease, illness or injury that is likely to respond quickly to the treatment that aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to your full recovery.

For example, if you twist your knee and require surgery on it, then as long as no exclusions apply, your PMI will cover the cost of the treatment. This is designed to reduce or relieve pain and get your knee back into the same state it was prior to the injury.

Chronic Conditions.

Your insurer will typically not cover the long-term treatment of  ‘chronic conditions’. These are diseases, illnesses or injuries that have one or more of the following characteristics:

  • It needs ongoing or long-term monitoring through consultations, examinations, check-ups and/or tests.
  • It needs ongoing or long-term control or relief of symptoms
  • It continues indefinitely
  • It comes back or is likely to come back
  • You need to be rehabilitated or specifically trained to cope with it
  • It has no known cure

A chronic example would be something like Asthma. The day to day management of asthma or other chronic conditions like osteoporosis, will not be covered under your PMI policy.

So while the costs of routine long-term treatment and monitoring of illnesses such as asthma will not be claimable, it’s important to note that acute flare-ups of chronic conditions may be covered. This will depend on the terms of your policy and your underwriting.

Cancer Treatments.

A cancer diagnosis has many of the characteristics of a  ‘chronic condition’ however medical insurance views cancer as an acute condition and subject to your underwriting, chosen benefits and terms and conditions will be treated for the long term.

Claiming.

If you believe that there is going to be a grey area surrounding a treatment that you will need, it’s vital that you always follow your insurer’s claims process to the letter. The claims process information can be found here: https://www.lessonmoore.co.uk/help/claiming-medical-insurance

Medical Opinion.

From time to time you and your medical team may disagree with your insurer’s view that your condition is chronic. Medical professionals do disagree and your team may feel your condition is acute, we certainly have supported some of our unluckier clients in presenting their cases to their insurer. Contrary to popular believe the insurers are not looking to avoid paying claims and their medical advisors will review complicated claims and will change their views when presented with compelling arguments. If you’re facing an issue with a claim do get in touch with us.

If after review you still feel that your insurer is wrong then The Financial Ombudsman will review the whole situation.

For more information about the ombudsman’s role, please visit the link here: http://www.financial-ombudsman.org/publications/technical_notes/private-medical-insurance.htm#acute1

Jack Webster

Health Insurance Consultant

September 2018.